Case Studies

Patient Safety


The issue:

An individual who had recently commenced employment as an HCA 
at a secure unit contacted their Guardian expressing concerns about the manner in which some patients were being managed. Initially the contact was very reluctant to provide details, expressing considerable fear for 
their own safety and employment. 

The Guardian worked with the individual over a two-month period as the story unfolded. This secure unit was a remote unit geographically from the Trust HQ and had in effect developed a subculture, which the Trust were not aware of. The staff member reported a series of instances over time that equated to patient bullying and abuse in the manner in which 
they were dealt with. 

This was a complex situation as the individual initially did not want us to report maters and was holding back critical information required by the Guardian in terms of escalation. Building trust and confidence in the individual, the Guardian finally got agreement to escalate with 
full disclosure.

The outcome:

The Trust began an immediate investigation of the circumstances confirming the concerns of the staff member to be accurate. A number of staff were disciplined, and one was dismissed for gross misconduct. The Trust implemented new review and oversight processes to ensure the situation would not repeat. The Trust also carried out a review of all other Secure Facilities extending the new oversight processes to all.